Family Stressors and Resources as Social Determinants of Health among Caregivers and Young Children

Life course-informed theories of development suggest it is important to integrate information about positive and negative aspects of the social environment into studies of child and parental wellbeing, including both stressors that compromise health and resources that promote well-being. We recruited a sample of 169 pairs of caregivers and young children (birth to 5 years) from a community health clinic and administered survey questions to assess stressors and resources. We constructed inventories of stressors and resources and examined the relationships between these inventories and caregivers’ depressive symptoms, anxiety symptoms, and sleep problems, and young children’s medical diagnoses derived from electronic health records. Cumulative stressors and resources displayed bivariate and adjusted associations with caregivers’ depressive symptoms, anxiety symptoms, and sleep problems. For depressive and anxiety symptoms, these associations were evident in models that included stressors and resources together. Caregivers with high stressors and low resources displayed the highest levels of depressive and anxiety symptoms and sleep problems. In terms of children’s health outcomes, only modest trends were evident for developmental/mental health outcomes, but not other diagnostic categories. Future studies are needed to examine stressors and resources together in larger samples and in relation to prospectively assessed measures of child well-being.


Introduction
Social context affects the health and wellbeing of parents and children, including stressors that compromise health and resources that promote well-being [1]. The interplay of compounding stressors and resources, shaped by the social determinants of health, influences healthy development and also health disparities by race/ethnicity and socioeconomic status, which emerge early in life and widen over time [2]. The accurate measurement of stressors and resources that affect infants and young children requires a comprehensive assessment of experiences in their parents' lives and an understanding of the broader social context in which families reside [3,4]. Within life course theory, an accumulation model suggests that the occurrence of multiple risk exposures exceeds the negative developmental consequences of a single exposure [5], often displaying a graded positive relationship [6][7][8][9]. More recently, studies have shown that an accumulation model also applies to the accrual of resources or assets in the family, with additional protective factors associated with a lower risk of poor health or increased well-being and resilience [10,11]. Whereas most research using an additive model has focused on either the accumulation of stressors [6] or resources [12], a variety of theories and frameworks within developmental psychology emphasize the importance of studying risks and protective factors together [13].
Several recent studies have examined childhood stressors and resources together for health outcomes in children [14,15] and adults [11,16,17]. For example, in a nationally representative study with children aged 8 to 17 (n = 40,302), adverse childhood experiences and positive childhood experiences interacted, whereby children who were exposed to high levels of adversity and low positive experiences had over 8 times the odds of depression compared to children with low adversity and high positive experiences [14]. In another study (n = 489, ages 10-13 years at baseline), researchers found that the ratio of childhood adversities to protective factors was associated with a range of health outcomes nearly ten years later [16]. Similar patterns are evident when outcomes are assessed in adulthood: for example, using data from a random digit-dial telephone survey of over 6000 adults in Wisconsin, positive childhood experiences were associated with a lower risk of depression, adjusting for adverse childhood experiences [11]. These studies align with other studies illustrating that positive social experiences can protect against the adverse health consequences of stressors [17][18][19][20]. In the present study, we build on existing research to examine stressors and resources together in relation to outcomes in young children and the parents of young children.
Social scientists and health practitioners have developed a wide array of options for high-quality measures of distinct family processes, attributes, and events relevant for characterizing the lives of caregivers and young children. Validated measures for specific parent or family characteristics, experiences, or contexts are typically long (e.g., ≥10 items), making it challenging to bring together multiple measures to characterize caregiver and young children's social environments comprehensively within research or clinical contexts, and to incorporate multiple detailed, multi-item assessments into analyses. With the increasing interest in integrating information about positive and negative aspects of children's social environment into research studies and clinical practices [11,[21][22][23][24][25], there is a need for brief yet robust measures to capture this information.
Guided by an accumulation model [6], in the present study, we constructed inventories of cumulative risk and protective factors using short scales and single-item questions to reflect stressors and protective factors across multiple domains relevant to children's development from infancy through five years of age and their parent's wellbeing. We focused this study on young children and their parents, given the importance of these earliest years for healthy development over time.

Participants
Our study team recruited 169 caregiver-child dyads from the waiting room of a single community health center in Massachusetts. Families were eligible for inclusion in this crosssectional study if the adult was a primary caregiver to a young child (ages 0 to 5 years) present in the clinic for an appointment. If eligible, the primary caregiver completed an informed consent process and the survey in English, Spanish, Portuguese, or Haitian Creole (i.e., the four most common languages spoken in this clinic population). Caregivers completed the surveys via a tablet while at the clinic, with help from research assistants as needed. Following survey completion, the research assistant added the child's medical record number to the survey record to make it possible to link the child's electronic health record (EHR) to the survey responses. The Institutional Review Board at Cambridge Health Alliance approved the study.

Measures
We collected information on a broad range of stressors and resources that can impact opportunities for healthy child development until five years of age. Experts from psychology, sociology, public health, and human development (some included in this authorship group) were asked to recommend brief yet validated questions for a range of stressors and resources recognized as central to parental wellbeing and child health. The overall goal was to create a survey with high-quality brief measures. The included constructs and associated measures were selected based on the current theories of early child development and research building on these models [1,[26][27][28], structured discussions, and eventual consensus among these experts. We retained the original items and response values, which are not consistent across items; as described below, following other research that has combined information across multiple measures with different scales [29,30], we created dichotomous variables for each construct to represent high or low values for each stressor or resource (described in more detail below). This approach to developing cumulative scores is widespread within child development research, as it is (a) parsimonious, (b) statistically sensitive with small samples, (c) avoids assumptions about the relative strengths of the component factors or their collinearity, and (d) fits with underlying theoretical models that suggest that multiple exposures are more potent than single exposures [6].

Cumulative Stressor Inventory
We constructed a cumulative stressor inventory that included 16 dichotomous indicators (range 0-16), created from the items listed in Table 1. The 16 included indicators reflect: (1) perceived stress in the past 12 months (1 Likert-style item); (2) major life events (5 dichotomous items) [31]; (3) everyday discrimination (5 Likert-style items) [32]; (4) housing instability (1 count item); (5) job instability (1 count item); (6) work schedule instability (1 Likert-style item); (7) job insecurity (1 Likert-style item); (8) work-life balance stress (1 Likert-style item); (9) financial insecurity (1 Likert-style item); (10) negative religious coping (2 Likert-style items); (11) neighborhood safety (1 Likert-style item); (12) family immigration concerns (1 Likert-style items, adapted from the National Survey of Hispanics); 26 stressful events during (13) the 12 months prior to conception of the child attending the clinic, (14) during pregnancy, and (15) since the child was born (with events selected from a variety of sources); and, (16) adverse childhood experiences of the respondent (8 dichotomous items) [33]. Table A1 in Appendix A presents correlations between the stressors, means, standard deviations, and ranges. In addition, this table shows the thresholds for dichotomization of each of the 16 indicators for use in the cumulative stressor score (i.e., top quartile, or closest approximation), as well as Cronbach's alpha for the Likert-style measures with multiple items. To create the cumulative stressor inventory score, we summed the indicator variables created for each measure. In addition to this continuous score, we constructed a quartile variable to examine graded patterns. You experienced a serious personal attack or assault 3.
Witness to a serious physical attack or assault 4.
Illness or accident when you nearly died 5.
Your spouse or child nearly died from an illness or accident No (0), Yes (1) responses; summed to create a count score.
Everyday Discrimination Scale

1.
You are treated with less courtesy or respect than other people.

2.
You receive poorer service than other people at restaurants or stores.

3.
People act as if they think you are not smart 4.
People act as if they are afraid of you 5.
You are threatened or harassed. I had to take care of a seriously ill or disabled member of the family; 3.
One of (child's name)'s parents or guardians died; 4.
Someone else very close to me died; 5.
I separated or got divorced from my husband or partner; 6.
I was apart from my partner due to military deployment or extended work-related travel; 7.
I argued with my partner more than usual; 8.
My partner was unfaithful to me; 9.
I had a major disagreement over child support, custody, or visitation; 10.
I experienced domestic violence or unwanted sexual contact; 11.
I had serious problems with a family member or close friend; 12.
My partner or I went to jail; 13.
I lived with someone who was mentally ill or suicidal, or severely depressed or abusing drugs or alcohol for more than a couple of weeks; 14. I

Stressful events, since child was born
Same as above.

Parent adverse childhood events
Looking back before you were 18 years of age: 1. Did you live with anyone who was depressed, mentally ill, or suicidal? 2.
Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs or abused prescription medications? 3.
Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility? 4.
Were your parents separated or divorced? 5.
Did your parents or other adults in your home ever slap, hit, kick, punch or beat each other, or your sibling(s)? 6.
Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Do not include spanking. 7.
Did a parent or adult in your home ever swear at you, insult you, or put you down? 8.
Did anyone at least 5 years older than you or an adult, ever touch you sexually, or try to make you touch them sexually, or force you to have sex?
Yes, No; summed to create a count score.

1.
Talk on the phone, text, or get together with family, friends, or neighbors 2.
Attend church or religious services 3.
Attend meetings of any other groups, clubs, or organizations Likert scale: Never/less than once per week (1)  What happens to me in the future mostly depends on me.

4.
We feel accepted for what we are.

5.
We are able to make decisions about how to solve problems. 6.
We confide in each other. I can trust the other caregiver to take good care of (child's name).

2.
He/she/respects the schedules and rules I make for (child's name).

3.
I can count on the other caregiver for help when I need someone to look after (child's name) for a few hours.

Combined Cumulative Stressors and Resources
To consider the co-occurrence of cumulative stressors and resources, we constructed a four-category variable to capture combinations of high and low scores on the cumulative stressors and resources inventories. For both inventories, we grouped quartiles 1 and 2 as "low" and quartiles 3 and 4 as "high" and created categories of (1) high stressors/low resources, (2) high stressors/high resources, (3) low stressors/low resources, and (4) low stressors/high resources.

Parental Well-Being Outcomes
The survey included brief measures of the caregiver's anxiety symptoms, depressive symptoms, and sleep difficulties. All three of these outcomes are important for sensitive and responsive parenting [38][39][40]. Anxiety symptoms were measured using the two screening items from a seven-item measure of generalized anxiety disorder (GAD) symptoms (i.e., the GAD-7, a validated and efficient tool for identifying anxiety disorder and severity) [41]. We used the mean of the two screening items to have scores for all participants (Cronbach's alpha = 0.86), as only those who screened as eligible for GAD received all seven items. The survey assessed depression using 7 Likert-style items (Cronbach's alpha = 0.64) from the eight-item version of the Center for Epidemiologic Studies Depression scale [42]. In the present analysis, we omitted one item due to high missingness resulting from an error in our electronic survey instrument (i.e., My sleep was restless). The survey measured sleep difficulties in the past four weeks using a three-item measure, with two items taken from the Alameda County Study and one item from the Women's Health Stress Study [43]. Respondents rated each of the three items on a four-point scale ranging from rarely/never to almost every day (Cronbach's alpha = 0.65).

Child Medical Record Diagnoses
We abstracted children's ICD-9-and ICD-10-based diagnoses from the electronic health record (EHR) and generated four dichotomous outcomes, including: (1) pediatric growth/nutrition (i.e., any diagnosis of preterm birth, low birth weight, underweight, obesity, loss of weight, or feeding problems in newborns); (2) laboratory abnormalities (i.e., any diagnosis of nutritional anemia, vitamin or nutrient deficiencies, or elevated lead levels or poisoning); (3) developmental/mental health (i.e., any diagnosis of communication disorders, chronic mental or developmental conditions, or disorders of learning or social functioning with onset in childhood); (4) asthma-like symptoms (i.e., any diagnosis of asthma or reactive airways). See Table A3 for ICD-9 and ICD-10 codes for the diagnosis of each illness.

Statistical Analyses
First, we generated descriptive statistics to summarize the sociodemographic characteristics of the study participants. To describe the bivariate relationship between the cumulative stressors and resources inventories and caregiver and child outcomes, we calculated mean scores by quartiles of the inventory scores, and for the four-category variable that combined across stressors and resources (using Student's t-tests and chi-square tests, respectively). As described above, we used quartile variables for the inventory scores (rather than continuous scores) to examine whether graded relationships exist and avoid assumptions of a linear relationship. Next, we applied regression models to estimate associations between caregiver symptoms and child health outcomes (dependent variables) and the continuous cumulative stressors and resources inventory quartiles (independent variables of interest), adjusted for socioeconomic and demographic characteristics. We used linear regressions to model associations for the caregiver outcomes (i.e., continuous symptom scores), adjusted for the respondent's age, sex, race/ethnicity, highest education in the household, and parental nativity. We did not apply adjusted models for the child outcomes given the sparse outcomes. Finally, we examined associations between the cumulative stressors and resources inventories as continuous scores, included individually and then together in models adjusted for the covariates described above. As a sensitivity analysis, we tested for multiplicative interactions between the continuous stressors and resources scores for the caregiver outcomes only.

Missing Data
Across the variables in our analysis, missing data ranged from 0 to 9 percent, except for depressive symptoms, which had missing values for 23 percent of respondents. We performed multiple imputation of missing observations using SAS, retaining all respondents that had enrolled. This strategy reduces the likelihood of non-response bias and best preserves the original sample characteristics. We generated 10 imputed datasets that were used in all analyses.

Demographic Characteristics
Of 169 caregivers in our analysis, 81 percent were biological mothers, and there was a similar proportion of boys and girls (see Table 3). Overall, 59 percent of the caregivers were between the ages of 26 to 35 years, and 10 percent were between 18 to 25 years of age. Sixty-three percent of the children were between the ages of 0 to 2 years. Seventyseven percent of the caregiver respondents were born outside the U.S. With respect to racial/ethnic composition, 39.1% identified as Hispanic, 23.7% as non-Hispanic White, 16.6% as non-Hispanic Black, 12.4% as non-Hispanic Asian, and 8.3% identified as "non-Hispanic other" race/ethnicity. Over one-third of the sample (36.3%) reported that the highest educational degree in the household is a high school degree or less, and 34.7% reported a college degree or higher.

Bivariate Associations between Stressors, Resources, and Health Outcomes
The first panel of Table 4 presents bivariate associations between caregiver and child health outcomes and the cumulative stressors score, with cumulative stress categorized in quartiles. Across the caregiver outcomes of depressive symptoms, anxiety symptoms, and sleep problems, there is a graded relationship between the cumulative stressors scores and the mean symptom scores, with the greatest symptom scores among those caregivers in the highest quartile of the cumulative stressors score. In contrast, there is no evidence of a graded relationship between quartiles of the cumulative stress score and child diagnoses.  1 Results are based on 10 imputed data files. 2 The phrase "low stressors" refers to Quartiles 1 and 2 of the Cumulative Stressors Inventory; "high stressors" refers to Quartiles 3 and 4 of the Cumulative Stressors Inventory. "Low resources" refers to Quartiles 1 and 2 of the Cumulative Resources Score; "high resources" refers to Quartiles 3 and 4 of the Cumulative Resources Inventory. 3 Child diagnoses refers to whether or not the child was diagnosed with any of the diagnoses in each of the diagnostic categories.
The second panel of Table 4 presents bivariate associations between caregiver and child health outcomes and the cumulative resources score. There was a clear inverse dose-response pattern between the cumulative resources score and depressive and anxiety symptoms, with the lowest mean symptom scores among those caregivers classified into the highest quartile of resources. An inverse relationship between cumulative resources and sleep was evident, but the lowest symptom score was for respondents in Quartile 3. Children's developmental/mental health outcomes displayed a bivariate association with the cumulative resources score, with children in the highest quartile for the cumulative resources score being the least likely to have a diagnosis. We did not observe any pattern for the relationships between the other child outcomes and the cumulative resources score.
The third panel of Table 4 displays the bivariate associations for the combined cumulative stressors and resources variable. Individuals in the high stressors/low resources category had the highest symptom scores for all three caregiver outcomes relative to the other categories, whereas individuals in the low stressors/high resources category had the lowest symptom scores for all three caregiver outcomes. The symptom scores were relatively similar for individuals categorized in the high stressors/low resources and low stressors/high resources groups. We observed an association between the combined cumulative stressors and resources variable and children's developmental/mental health outcomes, with over half of children (51.7%) who had this diagnosis categorized within the "high stressors/low resources" group; however, we did not observe patterns between this combined variable and the other child diagnostic outcomes.   1 Results are based on 10 imputed data files; linear regression models adjusted for caregiver's age, race/ethnicity and nativity, and highest educational level in the household. 2 The phrase "low stressors" refers to Quartiles 1 and 2 of the Cumulative Stressors Inventory; "high stressors" refers to Quartiles 3 and 4 of the Cumulative Stressors Inventory. "Low resources" refers to Quartiles 1 and 2 of the Cumulative Resources Score; "high resources" refers to Quartiles 3 and 4 of the Cumulative Resources Inventory.

Adjusted Associations between Stressors, Protective Factors, and Health Outcomes
Finally, in Table 6, we present associations between the continuous stressors and resources inventory scores and caregiver outcomes, with the stressors and resources scores included individually (Model 1), and then together (Model 2), in adjusted models. For models of depressive and anxiety symptoms and sleep problems, the cumulative stressors and resources inventories displayed associations when included individually and together (i.e., a positive association for the cumulative stressors inventory, an inverse association for the cumulative resources score, see Model 1). Furthermore, although the stressor and resource inventories are correlated (r = −0.39, p < 0.0001), the scores displayed independent associations with depressive and anxiety symptoms when included together (see Model 2), with the magnitudes of associations only slightly attenuated. In the model with sleep problems as the outcome, only the cumulative stressors score displayed a clear association, with greater stressors associated with more sleep problems, when the two scores were included together. In our sensitivity analyses, we did not find evidence for multiplicative interactions between the continuous stressors and resources scores for any of the outcomes in the adjusted models presented in Table 6. Table 6. Adjusted linear regression models to estimate associations between stressors and resources inventories and caregiver outcomes, included separately and together (n = 169) 1 .  1 Results are based on 10 imputed data files. a Separate models were used to estimate association between each cumulative score and the caregiver outcome, adjusted for caregiver's age, race/ethnicity and nativity, and highest educational level in the household. b The cumulative stressors inventory and cumulative resources inventory were included in a single model, adjusted for caregiver's age, race/ethnicity and nativity, and highest educational level in the household. Notes: The Cumulative Stressors Inventory and Cumulative Resources Inventory are correlated, r = −0.39, p < 0.0001. The p-values for the multiplicative interaction term (cumulative stressors by cumulative resources) were >0.05 for all outcomes.

Discussion
There are four key findings from our study. First, inventories of cumulative stressors and resources displayed strong associations with caregiver depressive symptoms, anxiety symptoms, and sleep problems, with cumulative stressors associated with worse outcomes, and cumulative resources associated with better outcomes. Second, the associations were evident in models that included stressors and resources together, for depressive and anxiety symptoms. Third, caregivers with high stressors and low resources displayed the highest levels of depressive and anxiety symptoms and sleep problems, indicating the value of considering stressors and resources together. Finally, with respect to children's diagnoses, we did not observe associations between the cumulative stressors or resources indices and the child outcomes, except for developmental/mental health outcomes, which showed some evidence for associations, although they were not robust. Taken together, our results indicate that our measure of cumulative stressors and resources was related to a range of caregiver outcomes, whereas this was not the case for diagnostic conditions in young children.
The observed associations for the caregiver outcomes are consistent with a broad literature documenting cumulative impacts of stressors and resources for adult mental health [44]. The lack of associations between the inventory of stressors and child diagnoses was unexpected based on the prior literature [6,45] and could be due to the low prevalence of diagnostic outcomes given the young age of the sample, or perhaps inconsistent recording within the EHRs. The children in this study were 5 years old or younger and therefore may not yet exhibit clinically relevant symptoms that would be detected or recorded in EHRs. Although we did not observe strong patterns with the child outcomes assessed in this study (via EHR), extensive research shows that parental mental health has implications for child development [38,[46][47][48]; therefore, further development of this assessment may be of value.
The current study builds on a variety of studies that have examined individual types of parental or family characteristics in relation to outcomes in young children and their parents (e.g., parental adverse childhood experiences [45], economic strain [49], discrimination [50], and optimism [51]). Our study included comprehensive assessments of both risk and protective factors, and we contribute to a growing research area to briefly yet systematically assess social and contextual factors that are important to health and well-being in children [21] and adults [52].
While interpreting the results from this study, it is important to consider several limitations. First, the cross-sectional design limited our ability to study the temporal ordering between our study variables, and therefore, this study is not designed to make causal inferences. Second, all child health outcomes were derived from EHRs, which could be incomplete and did not allow for the examination of continuous symptom scores, which may be ideal for young children such as those in this study. More subtle emerging developing deviations (e.g., fear, behavioral problems in preschool or at home, inadaptability to routine changes, etc.) may not be captured by most pediatric assessments or diagnoses. Third, the survey information was linked to the child's EHR, which contains diagnoses since birth, meaning our analyses cannot document temporal ordering for either child or adult health outcomes. Fourth, all measures of stressors and resources relied on relatively brief caregiver self-reports, and negative experiences may be under-reported, or positive experiences or attributes could be inflated. Fifth, given the design for this pilot study, which relied on convenience sampling, the sample is small and susceptible to selection bias. Finally, we conducted multiple tests because we had three caregiver outcomes and four child outcomes; however, given the sample size of this pilot study, we were not able to adjust for multiple comparisons.
Notably, this study also has several strengths, including (1) the unique community health clinic sample primarily comprised of racial/ethnic minorities and immigrants; (2) the translation of the survey into four languages to facilitate inclusion of non-English speaking families; and (3) the inclusion of numerous reliable and valid brief measures to comprise comprehensive inventories of stressors and resources, in line with the accumulation model, which is supported by the child development literature. In future research, it is important to examine the utility of this measure and other measures of cumulative stressors and resources, within longitudinal study designs that include repeated measures of child development. In addition, it will be informative to consider a broader range of outcomes in young children, beyond diagnostic conditions, including sleep [53], potential biomarkers of stressors [54,55], and child wellbeing outcomes [56,57] (e.g., happiness, self-esteem, and prosocial behaviors).
In conclusion, our study has documented clear associations between stressors and resources and parental outcomes, and these results are complemented by other studies showing the importance of parental wellbeing for optimal child development [58]. Future studies are needed to develop concise stressors and resources inventories using larger samples across a range of contexts, and these measures should be evaluated in relation to prospectively assessed measures of child well-being and symptomatology. This line of research holds promise for advancing the understanding of social determinants of health disparities for parents and children and informing interventions to prevent the emergence of health disparities.     The following categories from the chronic condition warehouse if not already included: ADHD, Anxiety, Autism, Intellectual Disability, Learning disability, Developmental Disability, PTSD